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Chronic Diseases, Exercise, and Physical Activity in Childhood: Off the Beaten Track

Tim Takken

The one million dollar question in our discipline might be how to get kids with chronic disease moving. Most of the current strategies are focused on children in our general population; However, children with disability are in desperate need of our attention since inactivity might be a bigger issue compared with their “healthy” peers. What we can learn (among others) from this year’s released Global Matrix on Physical Activity for Children and Youth (1), that many countries struggle to get their children moving. To get children with chronic disease or disability moving is even more challenging. In the current year, The Year That Was, I want to focus on two studies that might help us further on this topic.

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Chronic Diseases, Exercise, and Physical Activity in Childhood: 2015 in Review

Tim Takken

The year of 2015 was a fruitful year in the field of chronic diseases, exercise, and physical activity in childhood. Many interesting papers came out on this topic. Exercise testing and prescription in children with chronic disease and disability is an increasingly studied area in which many disciplines are involved including pediatric physical therapy, medicine, nursing, physical education, and exercise physiology. This multidisciplinary aspect is reflected in the journals in which my highlighted publications (below) were published. Because no single discipline has the ownership of exercise testing and prescription and because different disciplines use different jargon, it is difficult to have the scientific knowledge translated to the clinic. A few years ago we initiated the Pediatric Exercise Medicine Network (PEMNet) to close this knowledge translation gap.

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Chronic Diseases, Exercise, and Physical Activity in Childhood: 2016 in Review

Tim Takken

In this year’s review I want to make a case for exercise and physical activity in children with chronic disease or disability. Using two 2016 papers I will illustrate the infancy of the field, especially children who are wheelchair using. More efforts are needed to develop better methods to measure physical activity and exercise capacity in this population. In addition, effective interventions are needed to stimulate a healthy active lifestyle in children with disability. I sincerely hope that the 2016 review will stimulate other researchers to investigate physical activity and exercise in children with chronic disease and disability.

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Results From the Netherlands’ 2018 Report Card on Physical Activity for Children and Youth

Tim Takken, Nynke de Jong, and on behalf of the Dutch Physical Activity Report Card Study Group

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Validity of the Oxygen Uptake Efficiency Slope in Children With Cystic Fibrosis and Mild-To-Moderate Airflow Obstruction

Bart C. Bongers, Erik H.J. Hulzebos, Bert G.M. Arets, and Tim Takken

Purpose: The oxygen uptake efficiency slope (OUES) has been proposed as an ‘effort-independent’ measure of cardiopulmonary exercise capacity, which could be used as an alternative measurement for peak oxygen uptake (VO2peak) in populations unable or unwilling to perform maximal exercise. The aim of the current study was to investigate the validity of the OUES in children with cystic fibrosis (CF). Methods: Exercise data of 22 children with CF and mild to moderate airflow obstruction were analyzed and compared with exercise data of 22 healthy children. The OUES was calculated using data up to three different relative exercise intensities, namely 50%, 75%, and 100% of the total exercise duration, and normalized for body surface area (BSA). Results: Only the OUES/BSA using the first 50% of the total exercise duration was significantly different between the groups. OUES/BSA values determined at different exercise intensities differed significantly within patients with CF and correlated only moderately with VO2peak and the ventilatory threshold. Conclusion: The OUES is not a valid submaximal measure of cardiopulmonary exercise capacity in children with mild to moderate CF, due to its limited distinguishing properties, its nonlinearity throughout progressive exercise, and its moderate correlation with VO2peak and the ventilatory threshold.

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A Systematic Approach to Interpreting the Cardiopulmonary Exercise Test in Pediatrics

Marco Van Brussel, Bart C. Bongers, Erik H.J. Hulzebos, Marcella Burghard, and Tim Takken

The use of cardiopulmonary exercise testing in pediatrics provides critical insights into potential physiological causes of unexplained exercise-related complaints or symptoms, as well as specific pathophysiological patterns based on physiological responses or abnormalities. Clinical interpretation of the results of a cardiopulmonary exercise test in pediatrics requires specific knowledge with regard to pathophysiological responses and interpretative strategies that can be adapted to address concerns specific to the child’s medical condition or disability. In this review, the authors outline the 7-step interpretative approach that they apply in their outpatient clinic for diagnostic, prognostic, and evaluative purposes. This approach allows the pediatric clinician to interpret cardiopulmonary exercise testing results in a systematic order to support their physiological reasoning and clinical decision making.

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Is our Youth Cycling to Health? Results From the Netherlands’ 2016 Report Card on Physical Activity for Children and Youth

Marcella Burghard, Karlijn Knitel, Iris van Oost, Mark S. Tremblay, Tim Takken, and the Dutch Physical Activity Report Card Study Group


The Active Healthy Kids the Netherlands (AHKN) Report Card consolidates and translates research and assesses how the Netherlands is being responsible in providing physical activity (PA) opportunities for children and youth (<18 years). The primary aim of this article is to summarize the results of the 2016 AHKN Report Card.


Nine indicators were graded using the Active Healthy Kids Global Alliance report card development process, which includes a synthesis of the best available research, surveillance, policy and practice findings, and expert consensus.


Grades assigned were: Overall Physical Activity Levels, D; Organized Sport Participation, B; Active Play, B; Active Transportation, A; Sedentary Behaviors, C; Family and Peers, B; School, C; Community and the Built Environment, A; Government Strategies and Investments, INC.


Sedentary behavior and overall PA levels are not meeting current guidelines. However, the Dutch youth behaviors in sports, active transportation, and active play are satisfactory. Several modifiable factors of influence might be enhanced to improve these indicators or at least prevent regression. Although Dutch children accumulate a lot of daily PA through cycling, it is not enough to meet the current national PA guidelines of 60 minutes of moderate-to-vigorous PA per day.

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Validity of the Pediatric Running-Based Anaerobic Sprint Test to Determine Anaerobic Performance in Healthy Children

Bart C. Bongers, Maarten S. Werkman, Donna Blokland, Maria J.C. Eijsermans, Patrick van der Torre, Bart Bartels, Olaf Verschuren, and Tim Takken


To determine criterion validity of the pediatric running-based anaerobic sprint test (RAST) as a nonsophisticated field test for evaluating anaerobic performance in healthy children and adolescents.


Data from 65 healthy children (28 boys and 37 girls between 6 and 18 years of age, mean ± SD age: 10.0 ± 2.8 years) who completed both the pediatric RAST and the 30-s Wingate anaerobic test (WAnT) on a cycle ergometer in a randomized order were analyzed. Peak power (PP) and mean power (MP) were the primary outcome measures for both tests.


There were no significant sex-differences in PP and MP attained at the pediatric RAST and the WAnT. Age was strongly correlated to pediatric RAST and WAnT performance (Spearman’s rho values ranging from 0.85 to 0.90, with p < .001 for all coefficients). We found high correlation coefficients between pediatric RAST performance and WAnT performance for both PP (Spearman’s rho: 0.86; p < .001) and MP (Spearman’s rho: 0.91; p < .001).


The pediatric RAST can be used as a valid and nonsophisticated field test for the assessment of anaerobic performance in healthy children and adolescents. For clinical evaluative purposes, we suggest to use MP of the pediatric RAST when assessing glycolytic power in the absence of the WAnT.

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Oxygen Uptake Efficiency Slope in Healthy Children

Moniek Akkerman, Marco van Brussel, Bart C. Bongers, Erik H.J. Hulzebos, Paul J.M Helders, and Tim Takken

The objective of this study was to investigate the characteristics of the submaximal Oxygen Uptake Efficiency Slope (OUES) in a healthy pediatric population. Bicycle ergometry exercise tests with gas-analyses were performed in 46 healthy children aged 7–17 years. Maximal OUES, submaximal OUES, V̇O2peak, VEpeak, and ventilatory threshold (VT) were determined. The submaximal OUES correlated highly with V̇O2peak, VEpeak, and VT. Strong correlations were found with basic anthropometric variables. The submaximal OUES could provide an objective, independent measure of cardiorespiratory function in children, reflecting efficiency of ventilation. We recommend expressing OUES values relative to Body Surface Area (BSA) or Fat Free Mass (FFM).

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Validation of Accelerometer Prediction Equations in Children with Chronic Disease

Samantha Stephens, Tim Takken, Dale W. Esliger, Eleanor Pullenayegum, Joseph Beyene, Mark Tremblay, Jane Schneiderman, Doug Biggar, Pat Longmuir, Brian McCrindle, Audrey Abad, Dan Ignas, Janjaap Van Der Net, and Brian Feldman

The purpose of this study was to assess the criterion validity of existing accelerometer-based energy expenditure (EE) prediction equations among children with chronic conditions, and to develop new prediction equations. Children with congenital heart disease (CHD), cystic fibrosis (CF), dermatomyositis (JDM), juvenile arthritis (JA), inherited muscle disease (IMD), and hemophilia (HE) completed 7 tasks while EE was measured using indirect calorimetry with counts determined by accelerometer. Agreement between predicted EE and measured EE was assessed. Disease-specific equations and cut points were developed and cross-validated. In total, 196 subjects participated. One participant dropped out before testing due to time constraints, while 15 CHD, 32 CF, 31 JDM, 31 JA, 30 IMD, 28 HE, and 29 healthy controls completed the study. Agreement between predicted and measured EE varied across disease group and ranged from (ICC) .13–.46. Disease-specific prediction equations exhibited a range of results (ICC .62–.88) (SE 0.45–0.78). In conclusion, poor agreement was demonstrated using current prediction equations in children with chronic conditions. Disease-specific equations and cut points were developed.